Inspection on 06/02/07 for Ferndale Mews

This inspection was carried out on 6th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ferndale Mews 14/11/07

Ferndale Mews 11/11/05

Ferndale Mews 22/07/05

Ferndale Mews 25/01/05

Ferndale Mews 06/08/04

Ferndale Mews 23/02/04

Similar services:

Sunny Bank (P.R.S.) Ltd

Chirnside House

Ashwood Court Unit 1

Thornton Lodge

Emmaus House

East Croft Grange

Craignair

Alfred House Residential Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Ferndale Mews St Michaels Road Ditton Widnes Cheshire WA8 8TD Lead Inspector Joan Adam 6 /7 th th Unannounced Inspection February 2007 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ferndale Mews Address St Michaels Road Ditton Widnes Cheshire WA8 8TD 0151 495 1367 0151 424 4363 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.schealthcare.co.uk Southern Cross Healthcare Services Limited Carol Elizabeth Cummins Care Home 34 Category(ies) of Dementia - over 65 years of age (34), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (2) Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 34 service users to include :* Up to 34 service users in the category DE(E) (Dementia over 65 years of age) * Up to 2 service users in the category MD(E) (Mental disorder excluding learning or dementia over 65 years of age) Date of last inspection 11th November 2005 Brief Description of the Service: Ferndale Mews is a care home providing personal care for 32 older people with dementia who may also have physical disabilities and 2 people diagnosed with mental disorder. The home is located in the Ditton area of Widnes, close to local shops, pubs and St. Michaels church. The building is a storey purpose built home on the same site as Ferndale Court Care Home. All the bedrooms are single with en-suite facilities. There is a passenger lift. The home has a large secure rear garden. The current charges for the home are £485 to £839 per week. This information was provided by the home manager. Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process for Ferndale Mews included a site visit to the home on which was unannounced. The manager was attending training on the first day of the visit therefore the inspection was completed over two days. The home had 32 residents who receive residential care. Time was spent talking with the manager, staff and residents, and observing the day-to-day routines of the home and care staff as they provided support. A partial tour of the building was looked at to assess its suitability to provide a comfortable, homely environment for the enjoyment of residents and to ensure their safety. A sample of care plans and other records was looked at. Before the visit, comments cards were sent to residents and relatives, and the six residents and five residents who completed a questionnaire made positive comments. Positive comments cards were also received from four GPs and a social service professional who visit the home. The home manager completed a pre-inspection questionnaire. The home promotes equality by treating people as individuals and ensuring that diversity needs such as impaired mobility and gender are appropriately met. People who use the service confirmed that care staff are kind, caring and responsive to meeting individual’s needs. What the service does well: Assessments of people’s care needs are carried out before they move into the home so that residents know their needs can be met. Residents’ health, personal and social care needs are met by staff who enable them to maintain their privacy and dignity. Good relationships were seen to exist between residents and staff and those people that commented all said that the staff members were good. Residents spoken with said that they liked living in the home and comments such as “ the staff are lovely” and “ I am well looked after” were made by the residents. Relatives said that “ the staff are really good and treat the residents with respect.” Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 6 They can exercise choice and control over their lives and retain links with family, friends and the local community. Activities are on offer at the home to ensure that the residents living there are stimulated. Medication was managed satisfactorily to maintain the safety of the residents living at Ferndale Mews. Recruitment procedures, staff training and staff supervision ensure that residents are protected from harm. Residents’ financial interests are also safeguarded. The home is clean and comfortable with a warm and welcoming atmosphere. Residents say that they like living at Ferndale Mews. What has improved since the last inspection? What they could do better: Care plans are in place for all residents living at Ferndale Mews however, the recording of actions taken by staff in the daily records were inconsistent. One resident that had fallen had an accident form completed, however, the incident had not been recorded in the daily records. One resident that had two accidents had not had accident forms completed. The accidents had been recorded in the daily notes. The recording of daily occurrences and incidents must be improved to maintain the safety of the residents living at Ferndale Mews. Information regarding residents’ that had serious injuries had not been sent to CSCI or reported to RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences regulation 1995 as required. Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 7 Under Regulation 37 of the Care Homes Regulations 2001 the registered person is required to notify us, without delay, of any death, illness or other significant event within the home. The notice will then form part of the record of evidence for the care home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments of people’s care needs are carried out before they move into the home so that residents know their needs can be met. EVIDENCE: The files of two newly admitted residents who had moved into the home in recent months were looked at. It contained assessments of dependency levels, mental health needs and likes and dislikes. There was evidence that relatives had been involved in the pre admission process. The pre-admission assessments had been carried out by the manager. The home is not registered to take residents with intermediate care needs. Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Better recording needs to take place to ensure that residents’ health, personal and social care needs are met. Staff enable residents to maintain their privacy and dignity. EVIDENCE: The care plans of four residents were looked at. Care plans identified areas of need such as pressure area care, mobility, continence, nutrition, mental health needs and general dependency. The care plans contained sufficient information to provide care staff with the necessary information for them to look after a person’s needs. There was written evidence to confirm that care plans were being reviewed and evaluated Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 11 regularly. The care plans seen showed that there had been consultation with residents or their families/advocates. The care plan of one resident who had exhibited challenging behaviour had good recording of observations by staff and detailed reviews by health care professionals and the involvement of family members to enable the residents needs to be fully met. However, one residents plan stated that a bath or shower was to be offered on a daily basis. The recording of whether the hygiene needs of the resident were met were inconsistent. Staff spoken to stated that the resident often refused a bath or shower but her hygiene needs were met. This was not recorded in the care plan. One resident that had fallen had an accident form completed, however, the incident had not been recorded in the daily records. One resident that had two accidents had not had accident forms completed. The accidents had been recorded in the daily notes. The inconsistencies in the recording was discussed with the manager. Some daily and weekly recordings were detailed. The atmosphere at the home was warm and friendly and there was good staff interaction with the residents. Residents spoken with said that they liked living in the home and comments such as “ the staff are lovely” “ I am well looked after” “ this is a nice place” were made by the residents. Relatives said that “ the staff are really good and treat the residents with respect.” “ the staff are hard working and are very good” “ the staff are lovely, and I am always informed of any changes to my relatives condition.” Medication management and storage arrangements were looked at. The home used a monitored dosage system. Medication administration records were completed correctly. Medicines were stored correctly. Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines of daily living and activities available are flexible and varied to suit residents’ expectations, preferences and capacities. EVIDENCE: The home employs an activities co-ordinator. Activities on offer are manicures, hairdressing, sing-a -longs, bingo, reminiscence, exercise to music and one to one sessions with residents to read newspapers or magazines. Outside entertainers are booked at the home on a regular basis. Relatives said that they are always made welcome at the home. Religious preference is recorded in the care plan and ministers from the local churches visit the home regularly to hold services. Menus are varied and offer choice and nutritious meals. The dining rooms are pleasantly decorated. Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 13 Residents and relatives said that the food at the home was good. Residents said that they got enough to eat. Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a complaints procedure in place and the residents are protected from abuse. EVIDENCE: The home’s complaints procedure provides appropriate guidance and information as to how to make a complaint. There have been no complaints made to the home or CSCI since the last inspection. A copy of the complaints procedure is displayed on the wall in the main entrance. The home has an Adult Protection procedure (including Whistle Blowing), which complies with the Public Disclosure Act 1998 and the Department of Health Guidance “No Secrets”. The staff receive on going training on adult protection from the deputy manager. Both staff members and the home’s training records confirmed this. POVA issues at the home have been dealt with appropriately by the manager. Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ferndale Mews provides a comfortable environment for those living there and visiting. EVIDENCE: A tour of some areas of the home as undertaken. All the shared areas and a selection of bedrooms were seen. The home was well decorated and during the last year a number of bedrooms had been redecorated and new carpets had been laid. New carpets had been ordered for the corridors and were to be laid in within the next week. Bedrooms were well personalised with residents’ own furniture and mementoes. Additional equipment such as grab rails, raised toilet Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 16 seats and hoists were provided at the home as necessary to meet the residents’ needs. The home was cleaned to a high standard. Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels and skill mix are sufficient to meet the needs of the residents, Residents are protected by the home’s recruitment practices and staff training EVIDENCE: There were adequate numbers of staff on duty to meet the needs of the residents living at the home. There is ongoing training in place at the home for staff. A training matrix was seen. Training provided included care planning, moving and handling, fire awareness, first aid and a course on dementia care is to commence for all staff. A training programme is in place to enable staff to achieve NVQ level two in care. The home has thirty per cent of care staff who have completed the course. However, the government target of fifty per cent of all care staff to be qualified by 2005 has not been met. Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 18 Good policies and procedures are in place for the recruitment of staff. Four staff files were seen and each contained evidence of an interview, two references and the necessary CRB checks having been obtained before the staff member commenced duties. Evidence was seen to show that all staff working in the home have had a Criminal Records Bureau check completed. Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements need to be made to ensure the health safety and welfare of residents is protected. EVIDENCE: The home has an experienced manager who has been registered with the Commission for Social Care Inspection. She has obtained NVQ level four in management. The staff spoken with said that the home’s management team were approachable and supportive. Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 20 The operations manager for the company completes monthly unannounced visits and copies of these reports are kept in the home and sent to CSCI. These visits had highlighted some inconsistencies in the recording of information in care plans. A quality assurance system is in place which seeks the views of residents and relatives. Meetings are held on a regular basis and minutes are kept which are available in the manager’s office. Questionnaires are sent to residents and relatives and a report is completed. Day to day supervision was good and staff said they were well supported. Formal supervision was given to staff and records showed that the supervisor and staff member signed these. Small amounts of personal spending money are in safekeeping for most residents. Good records of all transactions are kept, and residents’ money is in individual envelopes. This is mainly used for hairdressing, newspapers and small items of shopping. The fire precautions record book was up to date and demonstrated that checks of the alarm system, emergency lighting, fire drills and staff training were taking place on a regular basis. Information sent to CSCI prior to the site visit recorded that safety certificates were in place for items of equipment such as hoists and passenger lifts and policies and procedures were up to date and accurate. However, information regarding residents’ that had serious injuries had not been sent to CSCI or reported to RIDDOR (reporting of Injuries, Diseases and Dangerous Occurrences regulation 1995 as required. Under Regulation 37 of the Care Homes Regulations 2001 the registered person is required to notify us, without delay, of any death, illness or other significant event within the home. The notice will then form part of the record of evidence for the care home. Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(2)(b) Requirement The registered person must keep the service users plan under review. The actions taken by staff at the home to meet the service users needs must be recorded. The registered person must maintain in respect of each service user a record which includes the information, documents and other records specified in Schedule 3 relating to the service users. All accidents must be recorded on the appropriate accident form and within the care plan. The registered person must give notice to the Commission without delay of the occurrence of any death, illness or other significant event within the home. Timescale for action 28/02/07 2 OP38 17(1) (a) 28/02/07 3 OP38 37(1) 28/02/07 Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP28 Good Practice Recommendations The home must have 5o of care staff qualified to NVQ level 2 or equivalent. Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ferndale Mews DS0000005188.V325959.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!